Antibiotic Use Following Ventilation for RSV Linked to Shortened Clinical Courses

Children with respiratory syncytial virus-associated lower respiratory tract infections (RSV-LRTI) commonly require pediatric intensive care unit admission and many patients receive invasive mechanical ventilation. Now, a new study reports that pediatric patients who were prescribed antibiotics at the onset of ventilation had shorter durations of both ventilation and hospital stay.

For the study, investigators set out to describe antibiotic prescribing practices over time for pediatric patients with RSV-associated acute respiratory failure who were receiving mechanical ventilation. Additionally, the investigators sought to assess whether earlier antibiotic prescription was associated with success of the patient’s clinical course.

The findings of the study were published in the journal Pediatric Critical Care Medicine, and presented in a late-breaker session at the Society of Critical Care Medicine's 48th Critical Care Congress.

“Current antibiotic prescribing practices in children with severe RSV-LRTI are important to assess in an era where antibiotic stewardship is emphasized to preserve antibiotic efficacy, reduce costs, and limit toxicity,” the investigators write. “In addition, exposure to antibiotics early in life may alter a child’s microbiome, which has been associated with future asthma.”

The investigative team comprised investigators from Rainbow Babies and Children’s Hospital, the University of Alabama at Birmingham, Boston Children’s Hospital, and Harvard Medical School.

With a focus on prescribing patterns during the first 2 days of mechanical ventilation among previously healthy young children, the investigators reviewed data obtained from the Pediatric Health Information System. From the database, the investigators collected information on a total of 2107 pediatric patients treated in the PICU for RSV-LRTI from 46 children’s hospitals across the United States.

The retrospective cohort study examined data from children less than 2 years of age who were discharged between 2012 and 2016 with no identified comorbidities. The investigators compared duration of mechanical ventilation and duration of stay with patients who received antibiotics during the first 2 days of ventilation and those not prescribed antibiotics during that period.

Findings indicate that the overall proportion of antibiotic prescriptions on the first 2 days of mechanical ventilation was 82%, a statistic that decreased over the study period (p = 0.004) and varied from 36% to 100% across centers.

The bivariate analysis found that the prescription of antibiotics was associated with a shorter duration of mechanical ventilation (6 days [4-9 days] vs 8 days [6-11 days]; p < 0.001) and shorter durations of hospital stay (11 days [8-16 days] vs 13 days [10-18 days]; p < 0.001).

“After adjustment for center, demographics, and vasoactive medication prescription, antibiotic prescription was associated with a 1.21-day shorter duration of mechanical ventilation and a 2.07-day shorter length of stay,” the investigators write in the abstract.

In total, 95% of children were prescribed antibiotics during hospitalization, but the time of prescription and duration of antibiotic use and the choice of antibiotics varied. Despite the variability, instituting antibiotics following mechanical ventilation was associated with a shortened clinical course after adjustment for the limited available covariates. Therefore, a delay in antibiotic use could result in poorer short-term outcomes.

The investigators conclude that in the future it could be beneficial to conduct epidemiologic studies to measure the prevalence of bacterial pneumonia in children with RSV-LRTI, along with evaluating available rapid diagnostic technologies and identifying accurate biomarkers of bacterial coinfection.

The study “Antibiotic prescription in young children with respiratory syncytial virus-associated respiratory failure and associated outcomes,” was presented on Monday, February 18, 2019, at the Society of Critical Care Medicine’s 48^th Critical Care Congress in San Diego, California.